Chapter 20 My Nursing Test Banks

An older resident is complaining of being constipated. Which action should the nurse take first when caring for this patient?

1. Assess the diet for adequacy of fiber and fluids.

2. Determine what the patient means by constipation.

3. Obtain an order for a laxative and an enema if needed.

4. Encourage the patient to increase fluid intake and activity.

Correct Answer: 2

Rationale 1: Assessing the diet for adequacy of fiber and fluids might be appropriate after the nurse determines how the patient defines constipation.
Reference: Page 574

Rationale 2: The nurse should first carefully evaluate the patients concern and question the person as to what is considered as being constipation. Determining the patients normal frequency of bowel movement, consistency of stool, and effort in passing stool is important before deciding to act.
Reference: Page 574

Rationale 3: Obtaining an order for a laxative and enema might be appropriate after the nurse determines how the patient defines constipation.
Reference: Page 574

Rationale 4: Encouraging the patient to increase fluid intake and activity might be appropriate after the nurse determines how the patient defines constipation.
Reference: Page 574

Rationale 1: A history of ulcerative colitis would not necessarily be associated with Clostridium difficile.
Reference: Page 572

Rationale 2: Steroid use is not associated with the development of a Clostridium difficile infection.
Reference: Page 572

Rationale 3: Clostridium difficile can be the cause of diarrhea in an older patient who has recently completed antibiotic use.
Reference: Page 572

Rationale 4: A diet poor in fresh fruits and vegetables and limited fluid intake would contribute to the development of constipation and not diarrhea caused by Clostridium difficile.
Reference: Page 572

Which interventions should the nurse use to reduce the risk of aspiration for an older patient with dysphagia?

Standard Text: Select all that apply.

1. Monitor during meals for a change in respirations.

2. Maintain an upright position for 1 hour after eating.

3. Raise the head of the bed to a 90 degree angle during meals.

4. Provide pureed solid foods and thin clear liquids during meals.

5. Ensure that one bite has been swallowed before providing another.

Correct Answer: 1,2,3,5

Rationale 1: An intervention to reduce the risk of aspiration in an older patient with dysphagia is to monitor the patient during meals for a change in respirations. This could indicate that the patient is aspirating food or fluids.
Reference: Page 561

Rationale 2: An intervention to reduce the risk of aspiration in an older patient with dysphagia is to maintain the patient in an upright position for 1 hour after eating.
Reference: Page 561

Rationale 3: An intervention to reduce the risk of aspiration in an older patient with dysphagia is to raise the head of the bed to a 90 degree angle during meals.
Reference: Page 561

The nurse instructs a family member on how to feed an older patient. Which observation indicates that the family member needs additional instruction?

1. Checks to make sure the patients dentures are in place

2. Makes sure that each bite is swallowed before providing the next bite

3. Reminds the patient to chew the food after being placed in the patients mouth

4. Tries to insert a utensil in the patients mouth and the patient bites down tightly

Correct Answer: 4

Rationale 1: The family member should ensure that the patients dentures are in place and in good repair.
Reference: Page 561

Rationale 2: Patients being fed must be given time to swallow what is in the mouth before being fed another bite.
Reference: Page 561

Rationale 3: Focusing attention on the task at hand and verbally reinforcing the expected activity may prove effective when feeding the patient.
Reference: Page 561

Rationale 4: The nurse should reinforce that forceful feeding techniques should not be used. Family members may feel frustrated if the patient does not cooperate with eating. Forcing the issue will likely lead to more power struggles at mealtime and the patient may simply not feel like eating.
Reference: Page 561

Which assessment finding should the nurse realize as being a cause for gastroesophageal reflux disease (GERD) occurring more commonly in older adults?

1. Increased amounts of saliva

2. Increased incidence of hiatal hernia

3. Tightening of the lower esophageal sphincter

4. The increase in peristalsis that occurs in the esophagus

Correct Answer: 2

Rationale 1: There is a decrease in the amount of saliva available to lubricate the food with aging.
Reference: Page 562

Rationale 2: There is an increased incidence of hiatal hernia that occurs with aging. Hiatal hernia occurs when a small portion of the stomach slides into the chest cavity trapping some of the stomach and its contents.
Reference: Page 562

Rationale 2: The heartburn is worsened by eating large meals and eating specific foods or beverages, which are often those high in fat or caffeine.
Reference: Page 563

Rationale 3: Approximately 10 to 15% of older patients with GERD develop Barretts esophagus, which is a precancerous inflammation of the cells lining the esophagus resulting from chronic exposure to the acid reflux.
Reference: Page 563

Rationale 4: The heartburn associated with gastroesophageal reflux disease (GERD) can cause chest pain that is so severe and persistent that the older patient is unable to distinguish the pain from cardiac pain and may seek emergency medical attention.
Reference: Page 563

3. Colorectal cancer occurs less frequently in those with a history of ulcerative colitis.

4. Colorectal cancer has no symptoms but can be detected by fecal occult blood testing.

Correct Answer: 4

Rationale 1: The risk of colorectal cancer rises with age and is the most common cancer after the age of 65.
Reference: Page 573

Rationale 2: Carcinoembryonic antigen (CEA) is not considered a diagnostic test but is used as a tumor marker to follow and manage the disease in patients diagnosed with the disease.
Reference: Page 573

Rationale 3: The incidence of colorectal cancer is increased in patients with a history of ulcerative colitis.
Reference: Page 573

Rationale 4: Colorectal cancer is asymptomatic in the early stages. Screening tools, such as annual fecal occult blood testing can detect the cancer when it is still in the curable stage.
Reference: Page 573

The nurse is assisting an older patient with dysphagia to eat an evening meal. Which foods on the patients tray should be avoided?

Standard Text: Select all that apply.

1. Hot tea

2. Custard

3. Pudding

4. Milkshake

5. Clear broth

Correct Answer: 1,5

Rationale 1: Thin food and liquids such as tea are difficult for older people with dysphagia to swallow. Thin liquids quickly drain into the esophagus before the swallow reflex is triggered.
Reference: Page 560

Rationale 2: Thickened liquids slow the swallow process, give the older person time to prepare for the swallow, and help prevent aspiration and dehydration.
Reference: Page 560

Rationale 3: Thickened liquids slow the swallow process, give the older person time to prepare for the swallow, and help prevent aspiration and dehydration.
Reference: Page 560

Rationale 4: Thickened liquids slow the swallow process, give the older person time to prepare for the swallow, and help prevent aspiration and dehydration.
Reference: Page 560

Rationale 5: Thin food and liquids such as clear broth are difficult for older people with dysphagia to swallow. Thin liquids quickly drain into the esophagus before the swallow reflex is triggered.
Reference: Page 560

An older patient with a history of constipation has been directed to use an over-the-counter medication to help manage symptoms of gastroesophageal reflux by buffering the gastric pH. Which medication would be the best for the patient to use?

Rationale 4: Sucralfate (Carafate) is a mucosal protectant agent that aids in mucosal healing by reducing direct tissue exposure to acid. Sucralfate works locally by forming an adherent complex that coats the ulcer site and protects it from further injury from acid, pepsin, and bile salts.
Reference: Page 565

An older patient, beginning antibiotic therapy for a leg wound, has a history of Clostridium difficile. What should the nurse instruct the patient to do to reduce the risk of this occurring?

1. Eat large amounts of fresh fruits and vegetables.

2. Restrict the amount of meat and calcium products.

3. Use acidophilus capsules while taking the antibiotic.

4. Decrease the amount of fluid taken while on the medication.

Correct Answer: 3

Rationale 1: Eating large amounts of fresh fruits and vegetables will not reduce the patients risk for developing Clostridium difficile.

Rationale 2: Restricting the amount of meat and calcium products will not reduce the patients risk for developing Clostridium difficile.

Rationale 3: Acidophilus capsules contain active cultures that can be used to treat a variety of gastrointestinal problems and as an adjunct to antibiotic therapy to prevent antibiotic-associated diarrhea caused by overgrowth of Clostridium difficile.

Rationale 4: Decreasing the amount of fluid taken while on the medication will not reduce the patients risk for developing Clostridium difficile.

The nurse is teaching an older patient with diverticulitis on foods that could precipitate a painful attack. How should the nurse instruct this patient?

1. Avoid foods with seeds.

2. Restrict the intake of high fiber foods.

3. Limit the intake of eggs and dairy products.

4. Eat whole grains with sesame seeds for added protein.

Correct Answer: 1

Rationale 1: The patient should be instructed to avoid foods that precipitate painful attacks such as foods with seeds like popcorn, sesame seeds, and poppy seeds. These seeds can become trapped in the diverticula and trigger an infection and inflammatory response.
Reference: Page 571